|
HYDROXYZINE PAMOATE 25 MG CAPSULE [3777]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 0555032302
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
HYDROXYZINE PAMOATE 25 MG CAPSULE [3777]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 0555032302
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.09
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.09
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE [17381]
|
Facility
|
OP
|
$273.92
|
|
|
Service Code
|
HCPCS J7325
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.02 |
| Max. Negotiated Rate |
$205.44 |
| Rate for Payer: Adventist Health Commercial |
$54.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$169.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.03
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$6.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.02
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$35.51
|
| Rate for Payer: Blue Shield of California Commercial |
$29.10
|
| Rate for Payer: Blue Shield of California EPN |
$29.10
|
| Rate for Payer: Cash Price |
$123.26
|
| Rate for Payer: Cash Price |
$123.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$126.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.53
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.62
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$175.31
|
| Rate for Payer: EPIC Health Plan Medicare |
$6.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$126.82
|
| Rate for Payer: Heritage Provider Network Senior |
$126.82
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.02
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$130.66
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$49.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$6.92
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.48
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8.07
|
| Rate for Payer: Multiplan Commercial |
$205.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$109.57
|
| Rate for Payer: TriValley Medical Group Senior |
$109.57
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$98.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$90.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.62
|
| Rate for Payer: Vantage Medical Group Senior |
$6.62
|
|
|
HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE [17381]
|
Facility
|
IP
|
$273.92
|
|
|
Service Code
|
HCPCS J7325
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.58 |
| Max. Negotiated Rate |
$205.44 |
| Rate for Payer: Adventist Health Commercial |
$54.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$176.40
|
| Rate for Payer: Cash Price |
$123.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$126.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$147.92
|
| Rate for Payer: Heritage Provider Network Commercial |
$126.82
|
| Rate for Payer: Heritage Provider Network Senior |
$126.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$49.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.48
|
| Rate for Payer: Multiplan Commercial |
$205.44
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$98.97
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$90.69
|
|
|
HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR [3781]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 5483851180
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR [3781]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 5483851180
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET [17023]
|
Facility
|
OP
|
$0.54
|
|
|
Service Code
|
NDC 4219233901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.33
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.46
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.46
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.33
|
| Rate for Payer: Heritage Provider Network Senior |
$0.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.26
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.38
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.46
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.46
|
| Rate for Payer: Vantage Medical Group Senior |
$0.46
|
|
|
HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET [17023]
|
Facility
|
IP
|
$0.54
|
|
|
Service Code
|
NDC 4219233901
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Adventist Health Commercial |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.35
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Senior |
$0.37
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
|
|
HYOSCYAMINE 0.5 MG/ML INJECTION SOLUTION [10239]
|
Facility
|
IP
|
$129.60
|
|
|
Service Code
|
HCPCS J1980
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$23.46 |
| Max. Negotiated Rate |
$97.20 |
| Rate for Payer: Adventist Health Commercial |
$25.92
|
| Rate for Payer: Adventist Health Commercial |
$15.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$83.46
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.00
|
| Rate for Payer: Cash Price |
$58.32
|
| Rate for Payer: Cash Price |
$35.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$59.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$69.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$60.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$36.67
|
| Rate for Payer: Heritage Provider Network Senior |
$36.67
|
| Rate for Payer: Heritage Provider Network Senior |
$60.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23.46
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.80
|
| Rate for Payer: Multiplan Commercial |
$97.20
|
| Rate for Payer: Multiplan Commercial |
$59.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$28.61
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$46.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$42.91
|
|
|
HYOSCYAMINE 0.5 MG/ML INJECTION SOLUTION [10239]
|
Facility
|
OP
|
$129.60
|
|
|
Service Code
|
HCPCS J1980
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.60 |
| Max. Negotiated Rate |
$110.16 |
| Rate for Payer: Adventist Health Commercial |
$25.92
|
| Rate for Payer: Adventist Health Commercial |
$15.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$48.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$80.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$110.16
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$67.32
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$43.56
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$71.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$97.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$59.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$17.60
|
| Rate for Payer: Blue Shield of California Commercial |
$55.08
|
| Rate for Payer: Blue Shield of California Commercial |
$55.08
|
| Rate for Payer: Blue Shield of California EPN |
$55.08
|
| Rate for Payer: Blue Shield of California EPN |
$55.08
|
| Rate for Payer: Cash Price |
$58.32
|
| Rate for Payer: Cash Price |
$35.64
|
| Rate for Payer: Cash Price |
$58.32
|
| Rate for Payer: Cash Price |
$35.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$59.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$110.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$67.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$67.32
|
| Rate for Payer: Dignity Health Medi-Cal |
$110.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$110.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$67.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$82.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$36.67
|
| Rate for Payer: Heritage Provider Network Commercial |
$60.00
|
| Rate for Payer: Heritage Provider Network Senior |
$36.67
|
| Rate for Payer: Heritage Provider Network Senior |
$60.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$61.82
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$37.78
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$14.34
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$23.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$32.40
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$55.44
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$90.72
|
| Rate for Payer: Multiplan Commercial |
$59.40
|
| Rate for Payer: Multiplan Commercial |
$97.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$51.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$31.68
|
| Rate for Payer: TriValley Medical Group Senior |
$51.84
|
| Rate for Payer: TriValley Medical Group Senior |
$31.68
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$46.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$28.61
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$42.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$67.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$110.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$110.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$67.32
|
| Rate for Payer: Vantage Medical Group Senior |
$67.32
|
| Rate for Payer: Vantage Medical Group Senior |
$110.16
|
|
|
HYPERTENSION WITH MCC
|
Facility
|
IP
|
$18,974.59
|
|
|
Service Code
|
MSDRG 304
|
| Min. Negotiated Rate |
$14,160.14 |
| Max. Negotiated Rate |
$18,974.59 |
| Rate for Payer: EPIC Health Plan Medicare |
$14,160.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14,160.14
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$16,284.16
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$18,974.59
|
|
|
HYPERTENSION WITHOUT MCC
|
Facility
|
IP
|
$12,296.51
|
|
|
Service Code
|
MSDRG 305
|
| Min. Negotiated Rate |
$9,176.50 |
| Max. Negotiated Rate |
$12,296.51 |
| Rate for Payer: EPIC Health Plan Medicare |
$9,176.50
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$9,176.50
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$10,552.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$12,296.51
|
|
|
HYPROMELLOSE 2 % INTRAOCULAR SYRINGE [29834]
|
Facility
|
IP
|
$75.60
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.68 |
| Max. Negotiated Rate |
$56.70 |
| Rate for Payer: Adventist Health Commercial |
$15.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$48.69
|
| Rate for Payer: Cash Price |
$34.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$34.78
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$35.00
|
| Rate for Payer: Heritage Provider Network Senior |
$35.00
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.90
|
| Rate for Payer: Multiplan Commercial |
$56.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$25.03
|
|
|
HYPROMELLOSE 2 % INTRAOCULAR SYRINGE [29834]
|
Facility
|
OP
|
$75.60
|
|
|
Service Code
|
HCPCS J3490
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.68 |
| Max. Negotiated Rate |
$64.26 |
| Rate for Payer: Adventist Health Commercial |
$15.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$46.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$64.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$41.58
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$56.70
|
| Rate for Payer: Blue Shield of California Commercial |
$46.12
|
| Rate for Payer: Blue Shield of California EPN |
$36.89
|
| Rate for Payer: Cash Price |
$34.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$34.78
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$64.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$64.26
|
| Rate for Payer: Dignity Health Medicare Advantage |
$64.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.38
|
| Rate for Payer: Heritage Provider Network Commercial |
$35.00
|
| Rate for Payer: Heritage Provider Network Senior |
$35.00
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$36.06
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$13.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$52.92
|
| Rate for Payer: Multiplan Commercial |
$56.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$30.24
|
| Rate for Payer: TriValley Medical Group Senior |
$30.24
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.31
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$25.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$64.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$64.26
|
| Rate for Payer: Vantage Medical Group Senior |
$64.26
|
|
|
HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE)
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 58555
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,672.00 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,579.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,163.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$3,672.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,579.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,163.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,163.48
|
| Rate for Payer: Heritage Provider Network Senior |
$5,121.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,163.48
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7,910.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,788.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,579.06
|
| Rate for Payer: Multiplan WC |
$6,436.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,579.83
|
| Rate for Payer: TriValley Medical Group Senior |
$4,579.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,454.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,273.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,579.83
|
| Rate for Payer: Vantage Medical Group Senior |
$4,163.48
|
|
|
HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION)
|
Facility
|
OP
|
$12,224.58
|
|
|
Service Code
|
CPT 58563
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,433.99 |
| Max. Negotiated Rate |
$12,224.58 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9,650.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7,077.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6,433.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$8,435.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,650.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,077.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6,433.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,433.99
|
| Rate for Payer: Heritage Provider Network Senior |
$7,913.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6,433.99
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$12,224.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7,399.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8,621.55
|
| Rate for Payer: Multiplan WC |
$9,993.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,077.39
|
| Rate for Payer: TriValley Medical Group Senior |
$7,077.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10,001.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,445.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,650.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,077.39
|
| Rate for Payer: Vantage Medical Group Senior |
$6,433.99
|
|
|
HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD)
|
Facility
|
OP
|
$12,224.58
|
|
|
Service Code
|
CPT 58559
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,245.00 |
| Max. Negotiated Rate |
$12,224.58 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9,650.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7,077.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6,433.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,245.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,650.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,077.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6,433.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,433.99
|
| Rate for Payer: Heritage Provider Network Senior |
$7,913.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6,433.99
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$12,224.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7,399.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8,621.55
|
| Rate for Payer: Multiplan WC |
$9,993.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,077.39
|
| Rate for Payer: TriValley Medical Group Senior |
$7,077.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,454.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,273.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,650.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,077.39
|
| Rate for Payer: Vantage Medical Group Senior |
$6,433.99
|
|
|
HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 58562
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,163.48 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,579.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,163.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,158.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,579.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,163.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,163.48
|
| Rate for Payer: Heritage Provider Network Senior |
$5,121.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,163.48
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7,910.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,788.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,579.06
|
| Rate for Payer: Multiplan WC |
$6,436.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,579.83
|
| Rate for Payer: TriValley Medical Group Senior |
$4,579.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,454.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,273.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,579.83
|
| Rate for Payer: Vantage Medical Group Senior |
$4,163.48
|
|
|
HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA
|
Facility
|
OP
|
$12,224.58
|
|
|
Service Code
|
CPT 58561
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$6,245.00 |
| Max. Negotiated Rate |
$12,224.58 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9,650.99
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7,077.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6,433.99
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6,245.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9,650.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$7,077.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$6,433.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$6,433.99
|
| Rate for Payer: Heritage Provider Network Senior |
$7,913.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6,433.99
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$12,224.58
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$7,399.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$8,621.55
|
| Rate for Payer: Multiplan WC |
$9,993.72
|
| Rate for Payer: TriValley Medical Group Commercial |
$7,077.39
|
| Rate for Payer: TriValley Medical Group Senior |
$7,077.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$10,001.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8,445.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9,650.99
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7,077.39
|
| Rate for Payer: Vantage Medical Group Senior |
$6,433.99
|
|
|
HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C
|
Facility
|
OP
|
$9,616.00
|
|
|
Service Code
|
CPT 58558
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,163.48 |
| Max. Negotiated Rate |
$9,616.00 |
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4,579.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4,163.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5,158.00
|
| Rate for Payer: Blue Shield of California Commercial |
$8,962.13
|
| Rate for Payer: Blue Shield of California EPN |
$7,178.49
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$4,579.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$4,163.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$9,616.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$4,163.48
|
| Rate for Payer: Heritage Provider Network Senior |
$5,121.08
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$4,163.48
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$7,910.61
|
| Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage |
$4,788.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$5,579.06
|
| Rate for Payer: Multiplan WC |
$6,436.87
|
| Rate for Payer: TriValley Medical Group Commercial |
$4,579.83
|
| Rate for Payer: TriValley Medical Group Senior |
$4,579.83
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7,454.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6,273.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6,245.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4,579.83
|
| Rate for Payer: Vantage Medical Group Senior |
$4,163.48
|
|
|
IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE [70544]
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
HCPCS J1740
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.10 |
| Max. Negotiated Rate |
$339.85 |
| Rate for Payer: Adventist Health Commercial |
$20.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$61.80
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$85.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$55.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$75.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$339.85
|
| Rate for Payer: Blue Shield of California Commercial |
$81.60
|
| Rate for Payer: Blue Shield of California EPN |
$81.60
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$46.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$85.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$85.00
|
| Rate for Payer: Dignity Health Medicare Advantage |
$85.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$64.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.30
|
| Rate for Payer: Heritage Provider Network Senior |
$46.30
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$47.70
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$70.00
|
| Rate for Payer: Multiplan Commercial |
$75.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$40.00
|
| Rate for Payer: TriValley Medical Group Senior |
$40.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$36.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$33.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$85.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$85.00
|
| Rate for Payer: Vantage Medical Group Senior |
$85.00
|
|
|
IBANDRONATE 3 MG/3 ML INTRAVENOUS SYRINGE [70544]
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
HCPCS J1740
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.10 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Adventist Health Commercial |
$20.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$64.40
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$46.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.30
|
| Rate for Payer: Heritage Provider Network Senior |
$46.30
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$18.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.00
|
| Rate for Payer: Multiplan Commercial |
$75.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$36.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$33.11
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 9994200275
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 9994200274
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.04
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$0.04
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
IBUPROFEN 100 MG/5 ML ORAL SUSPENSION [10246]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 6809450362
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
